In a recent post, Health Beat described the policy strategies that must be employed in order to address the primary care crisis in the United States. Here, I’d like to focus to the human side of the primary care crunch by highlighting the personal experiences of doctors. Moving from the policy to the personal adds an all-important qualitative element to our understanding of just why American primary care is in such dire straits.
That said, numbers still help set the stage: in 1990, 9 percent of graduating medical students planned to work in primary care/internal medicine; today just 2 percent are choosing primary care. Meanwhile, we know that primary care can help patients avoid expensive, unnecessary medical procedures; obtain regular preventive care; and manage the chronic illnesses that make up between 75 and 80 percent of our $2.3 trillion national health care bill. We can’t afford to run out of PCPs.
The usual reasons cited for the dwindling ranks of PCPs are money and time. Many PCPs make only 1/5 as much as the best-paid specialists. Lower salaries mean that PCPs need to see more patients to have incomes that are comparable to those of their peers. This imperative creates a “hamster wheel” as PCPs frantically cycle through patients who often are suffering from complex, chronic diseases.
No Time to Learn
It’s generally agreed that primary care is unpopular because medical students see the money/time crunch and tell themselves, “no way is that going to be my life.” But the Over My Med Body! blog, which until recently had been maintained by a medical student named Graham, offers a slightly different perspective. According to Graham, students aren’t necessarily mapping out their whole lives when they select a field and apply for residencies—they just want the chance to develop their analytical acumen and grow as doctors. The hamster wheel doesn’t give them that opportunity.
“In subspecialty outpatient clinics, there’s more time to spend with
patients,” says Graham. “Visits are usually scheduled as 30 minutes
long,” twice as long as the 15-minute standard for primary care visits.
The frenetic pace of primary care makes students a hypertension,
diabetes, hyperlipidemia, peripheral neuropathy, prior MI [myocardial
infarction], stroke, and liver disease (not to mention learning all the
drugs and dosages).” Students and fresh-faced doctors simply can’t get
their bearings; so they abandon the field.
“Of course we like the specialties where we have more time to
figure out all our patients’ problems,” says Graham. Time lets
residents develop their expertise and feel that they can improve as
doctors. As the saying goes, you have to walk before you can run; but
with primary care, you have no choice but to hit the ground running.
Another downside to the hamster wheel is that it provides little
time for doctor-patient interaction. “[W]e got into medicine to help
patients, not just cure their disease,” says Graham. “[Medical
students] prefer to have the time to get to know our patients as
people, not just as the guy with poorly controlled diabetes with
hemoglobin A1C’s in the 10-12 range.” In primary care, they don’t get
This is heartbreaking to acknowledge. With its professional emphasis
on patient consultation and care coordination, primary care is supposed
to be the most patient-centric field of medicine. But in the eyes of
med students it lacks the very human element that—in theory—should be
at the center of a family doctor’s practice.
“Assembly Line” Medicine
Sadly, many established pros would feel inclined to agree with this assessment. In a 2006 op-ed for the Boston Globe,
an ex-PCP in Massachusetts named Annie Brewster describes how primary
care ended up being far less personal than she had hoped. Initially,
Brewster “chose primary care because [she] love[s] people,” and because
she “wanted to take care of the whole person, body and mind.” But after
a few years of practicing, Brewster was “drowning in this overwhelmed
state,” in which she lost her “ability to take good care of people.”
To keep up with patient visits, Brewster had to “move frantically
from exam room to exam room.” She found it “impossible to know all of
[her patients] well, to give adequate focus to each person’s unique
situation, [and] to sift through the piles of paperwork and lab data
daily.” At one point, Brewster—who had long aspired to be close with
her patients—“walked into an exam room…and introduced [her]self to a
patient. ‘We have met before,’” replied the patient, understandably
annoyed. Brewster was “horrified and saddened” that she had become so
desensitized to her patients. She left primary care and now works as an
urgent care physician.
Like Annie Brewster, Theresa Chan had always loved the idea of being a PCP. According to a recent post
on her blog, Chan entered primary care because of what she calls “the
Dream of Family Practice”—an ideal where “doctors represent the health
of families and the community” and stay with patients “from womb to
tomb,” performing functions that are “fundamental to people’s
But, also like Brewster, Chan saw her “Rockwellian utopia of
medicine” fall apart, albeit for slightly different reasons. One
potentially frustrating reality of primary care is that it’s more
interactive than other types of medicine. As Beverly Woo, a PCP
affiliated with Harvard University, noted in a 2006 commentary for the New England Journal of Medicine,
the scope of primary care often requires sensitive interactions:
“[b]ecause primary care doctors are often the only physicians whom a
patient visits, we must identify problems that are frequently difficult
to talk about, such as alcohol and drug use, domestic violence, and
risky sexual practices,” says Woo. PCPs also have to keep tabs on “how
social factors affect patients who have chronic diseases.” Woo notes
that “[one patient named] Mr. S. had a relapse of alcoholism after
separating from his wife, Ms. R.’s glycated hemoglobin level
skyrocketed when her daughter became ill, and Ms. H. had an
exacerbation of her colitis when she lost both her job and her
housing.” More than any other type of doctor, PCPs have to engage with
the lives of their patients, an often touchy endeavor. When people find
themselves in tough times, even simple discussions can become volatile
It was this volatility that eventually drove Chan from primary care. Over time, she became fed up with the pushback
she constantly received from patients. They “yelled at the front desk
staff when they had to wait half an hour” and “cussed out our triage
nurses”; patients “stormed out of exam rooms” and threatened “clinic
staff for what most reasonable people would consider minor annoyances.”
Ultimately, Chan spent “a disturbing amount of time managing people’s
expectations and making ‘behavioral contracts’ with” unruly patients in
order to continue providing care. Being a referee and a disciplinarian
“is not what I went into medicine to do,” she says.
While primary care will always maintain a certain amount of
unpredictability, Chan’s experience was made much worse by the volume
of patients she received. Difficult patients are one thing, but dealing
with difficult patients in 15-minute intervals has a cumulative effect:
Chan acknowledges that she would sometimes have to cut short visits
with reasonable, amicable patients in order to deal with the difficult
ones and still maintain her schedule. The sad truth is that the pace of
primary care work leaves little wiggle room, meaning that, when
complications arise, something has to give—even if it’s good, decent
patients who need help.
Ultimately, Chan left primary care and now works as a hospitalist.
Like Graham, who felt that primary care wouldn’t allow him room to
grow, and Annie Brewster, who lost touch with her patients, Chan came
to realize that she wasn’t living up to her aspirations as a doctor.
All three had a similar thought when they observed the realities of
primary care: this is not why I wanted to become a doctor.
too many PCPs are burning out as they watch their ideals crumble in the
face of the day-to-day realities of their practice. But let’s be clear:
none of this is to say that there’s no hope for primary care on the
whole. In the past, we’ve talked about how to fix the problems, because
they are fixable. But do take these stories seriously; they do more to put the state of primary care into perspective than statistics ever could.
In Part 2 of this post, I’ll talk more about the reality of primary
care—including its upsides—and how we can create a health care system
that nurtures PCPs instead of breaking their spirits.